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M dn D <br />721 D <br />C-.) (f) <br />lm� cr ' <br />r-T1 z <br />/ rn <br />.� ( O LU <br />C O G�J <br />r CD CIO <br />m 3 r � <br />CD � r A oCD <br />aCJ <br />Frac. Lot 4 in Frac. Blk. 25 of Baker's Additionrand its complement Frac. <br />Lot 4 in Frac. Blk 4 in Woodbine Add., Hall County, NE. <br />WHEN TEAS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH Aig"MULSERWCES <br />SYSTE14 /T CERnFES ThE BELOW TO BE A TRUE COPY OF THE ORIGINA.4 -WC000 G AftA ;'TH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAIMsl IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />-2-00010531 <br />JUN 17 1998 = == <br />AsM-WANT STATE REG <br />LINCOLN, NEBRASKA HEALTH ANDWAE4IIIjERVIQWYSjM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S&#I('BS FiNA1VC AND SFfPPORT 98 - 7244 <br />VITAL STATISTICS - -- <br />CFRTTFIrATF nF nPATf-f �? - <br />1 DECEDENT - NAME FIRST MIDDLE LAST <br />Interval between onse and Beam <br />2. SEX <br />3. DATE OF DEATH /Monte. Day Yearl <br />Clara S <br />Glade <br />Female <br />June 11, 199$ <br />4. CITY AND STATE OF BIRTH tllnotkr USA.. namecountry/ <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to me dea:h but ne: related PART <br />PART <br />5a. AGE - Last Birthday <br />UNDER t <br />YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH tMarM Day. Yearl <br />Grand IS Nebraska <br />rral 79 <br />November 20, 1918 <br />sb. Mos I <br />DAYS <br />Sc. HOURS' MINS <br />7. S%%Sftfg6WyBER <br />26a <br />Ba. PLACE OF DEATH <br />,(J, 4 U,/ <br />26d. DESCRIBE HOW INJURY OCCURRED <br />HOSPITAL. <br />- -- <br />® Inpatient OTHER. Nursing Home <br />1:1 ER Outpatient Residence <br />8b. FACILITY - Name Ill nor msMUtion. give street and number) <br />St. Francis Medical Center <br />M <br />❑ GOA <br />2•e. INJURY AT WORK <br />261. Lq street. factory <br />bultlirg�elRV <br />26g LOCATION STREET OR R.F D NO CITY OR T, OWN STATE <br />Other(Specdvr <br />Sc CITY TOWN OR LOCATION OF DEATH <br />❑ <br />8d. INSIDE CITY LIMITS <br />Be, COUNTY OF DEATH <br />Grand Island <br />Yes � <br />Hall <br />No <br />9a. RESIDENCE - STATE 9b COUNTY <br />Nebraska <br />28a. DATE SIGNED (Mo. Day Yr I <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER 'including Zip Codel ge, INSIDE CITY LIMITS <br />Hall <br />Grand Island <br />20i9 West ist Street, 68803 <br />M <br />i <br />Yes [X] No ❑ <br />10. RACE - (e.g.. While. Black. American Indian. <br />11. ANCESTRY leg. Italian. Mexican. German, etc) <br />12. MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE Ill wde give maiden name) <br />` hit& <br />Aofn'trican <br />NEVER DIVORCED <br />R 1 <br />Henry D. Glade <br />t.a. �UaSvUAALLpOCCUPATION lGive kindo/ work dare during most <br />rudl <br />14b KIND OF BUSINESS INDUSTRY <br />`s <br />LY <br />15. EDUCATION (Specify only highest grade completed) <br />Elemelt2y or Secondary f0 -121 Collet n 4 or � -I <br />nV"'VIWM` <br />Domestic <br />II FATHER - NAME FIRST MIDDLE <br />LAST <br />1 7 MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Jakob <br />Scheibe) <br />Si nature and Tdle <br />Marie Zeiler <br />r/m . trunk.) I fit yes. give war and dates of services) I Henry (Dick) Glade <br />1-- INFORMANT MAILING ADDRESS (STREET OR R F D NO., CITY OR TOWN. STATE. ZIP) - <br />2019 West 1st Street, Grand Island, Nebraska 68803 <br />A., Er. ALMER - SIGNATURE 8 LICENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME <br />3y 06/15/1998 Grand Island City Cemetery <br />A"'Y Burial Removal <br />a FUNERA OME - NAME - / 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Geddes Funeral Home R Cremation ❑ Donaton Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). lb), AND (c)) Interval between onset ano oeam <br />PART /,-I //'�, �( <br />fai <br />DUE TO. OR AS SEQUENCE OF <br />Interval between onse and Beam <br />I <br />DUE TO. OR AS A CONSODUENCE OF <br />1 Interval between onset and deam <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to me dea:h but ne: related PART <br />PART <br />81 IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />II <br />PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER' <br />(Ages 10 -541 Yes No <br />Yes No <br />Yes No <br />26a <br />26b DATE OF INJURY tMo.. Day. Yr.) <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />r n Acodem ❑ Undetermined <br />M <br />Su,ade Pending <br />2•e. INJURY AT WORK <br />261. Lq street. factory <br />bultlirg�elRV <br />26g LOCATION STREET OR R.F D NO CITY OR T, OWN STATE <br />--cde Investigation <br />Yes ❑ No <br />❑ <br />office /ASpecry / /'farm. <br />271t ,PATE OF DEATH (MO. Day. Yr) <br />28a. DATE SIGNED (Mo. Day Yr I <br />28b TIME OF DEATH <br />= <br />June 11, 1998 <br />g� <br />be <br />M <br />i <br />27b DATE SIGNED (Mo.. Day Yr) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD /Mo.. Day. Yr) <br />28d. PRONOUNCED DEAD (Hour) <br />E a <br />go <br />June 12, 1998 <br />6:30 a. M��€ <br />M <br />g <br />27tl. to the best of my knowletl���rr <br />e, date a lace and tlue tot <br />28e. On the basis of examination and or investigation, in my opinion deals occurred at <br />causelsl statetl. <br />v a <br />the lime, d ata and place and due to the causes) stated. <br />(Signature and Title) ► <br />Si nature and Tdle <br />29. DID TOBACCO USE CONTRIBUTE 0 THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONS <br />30.b WAS CONSENT GRANTED' <br />F1 YES NO UNKNOWN <br />/IDERED? <br />a YES 110 <br />YES E,- <br />nrarye,ry un uvurvrr nl l-n T //fire s ' 41 <br />Dr. Daniel R. Cronk, 908,N. Howard A�., ,Vrand Island, Nebraska 68803 <br />/nl e <br />REGISTRAR J/ <br />BY REGISTRAR (MO.. Day Yr.) <br />.JUN 1 R 199R <br />�v <br />\a <br />